HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 SUMMER STREET 5/13/2024 Commonwealth of Massachusetts i _� ` ` �. `; � Andover
w City/Town of pY 13 2024
System Pumping Record M
Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. ----
HOUSE: front e� side rear(Fllright
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not � MA � 1kck-
key.use the return City/Town State Zip Code
2. System Owner:
Q
euit-NL-Gt��i�r
Name
serum
Address(if different from location)
MA
City/Town State Zip Code
'P '130-8��s
Telephone Number
B. Pumping Record
1. Date of Pumping � 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): VNo
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. non where contents were disposed:
hol`�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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